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Am- - WOE <br /> 1001VUt0 0611TAL HEALTH DIVISION <br /> APPLICATION POR UNDERGROUND TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/IF1rG'ORARY 0 URE OR ABANDONMENT <br /> IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK. <br /> THIS PERMIT MIRES 90 DAYS FROM THE APPROVAL DATE. <br /> DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> REMOVAL RARY CLOSURE CLOSURE IN PLACE <br /> EPA Site 4 Pmjact Contact A Telephone 4 <br /> F CA2990090002 C.Snsi Jackson 510 423.6577 <br /> A Facility Name Pbone 4 <br /> C Lawrence Livermore National Libamtoff Site 3001(510)423-401 <br /> I Mailing Address 7000 Eau Avenue.P.O.Box 808.Ummom.CA 94350 <br /> L Site Address:Corral Hollow Road,south of T <br /> I Cross Street <br /> T located 15 aides east of Livermore an Corral HAow Raad Tesla Rad and h 580 <br /> Y OwnerlOperaror Pbone 4 <br /> U.S.Govenurma,University of California (510)4 <br /> C-M--°r Name Pbooe 4 O$-4 53-1��� <br /> C cim <br /> O Coam ctor Address CA Lic• <br /> N 4 mfh.t S1. 30 5 0 9 <br /> T lnmw Wait.Comp.4 <br /> R <br /> A Fite District Pamit 4 <br /> C LLNL,Site 300 Fut Dmment <br /> T Labm-may Name Pbone 4 <br /> O Clayton Environmental Consultants (5 10)4262600 <br /> R Sampling Frm Pbooe a <br /> EnvQvrmmsal Protection t Sl 4234rM <br /> Task • Tank Size Chemicals Stored Carrentl lPrevioasl Date UST Install <br /> ed <br /> 39- 3— 8 Ions diesel fuel 1967 <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P Approved Approved with Coudition(s) _pwpproved <br /> L —(See Attachment Conditions) <br /> A <br /> N Plan Reviewers Name to <br /> APPLJCANr;=PERFORM ALL WORK IN ACCORDANCE WITH SAN)OiAQU N ORDtA1ANCJ S.STATE LAWS.AND <br /> RULES AND RB3ULA=M OF SAN XOA"CDt1NTY KML IC HEALTH SERVICEf OWNER OR 13MISED AGENTS <br /> SIGNATURE C onMI S THE POL1DWIIr['r 7 CFR'I>FYTHAT IN DM pEp50RMANCE OF THE WORK FOR WKCH 7M PMMIT <br /> B ISSUED.I SHALL NOT EMPLay ANY PERSON JN SUCH A MANNER AS TO SBCOME SURWrTO WORKERS COWENSATMN <br /> LAWS OF CALMMORAIIA.' CON TRAC1URS HIILING OR SUBCONTRACTM SMATURE CERTUM THE FOUO'W 04C: 7 <br /> CFR igY THAT IN THE !4F THE WORK FOR WHICH THIS PDWQT 15 6SUM I SHALL DOWY PERSONS <br /> SUBJECTTO WORKER, S RNID <br /> APPLICANT'S SIGNATURE::::; <br /> 'n'IZF DATE ro Es <br /> EH 23 046(REV 7/10,92) rfr <br /> 3 <br />